Orthopaedics Flashcards
Bicep reflex
C5/C6
Tricep reflex
C6/C7
Abdominal reflex
T8 - T12
Knee reflex
L3/L4
Ankle reflex
S1/S2
Brachioradialis reflex
C5/C6
Grading of reflexes
0 = absent
1 = hypoactive
2 = normal
3 = hyperactive, no clonus
4 = hyperactive + clonus
Factors affecting fracture healing
Local trauma: soft tissue injury, tissue loss, sort tissue interposition, neurovascular injury, open fractures
Inadequate reduction and immobilisation
Infection
Location: metaphysics vs diaphysis
Metabolic
Age, NSAIDs, T2DM, Smoking
Perkin’s rule of fracture healing
Fracture of cancellous bone - metaphysical approx 6 weeks
Fracture of cortical bone - diaphysial approx 12 weeks
Fracture of tibia approx 24 weeks
Children, age plus 1 in weeks
Definition of delayed union
1.5x times normal fracture time
Definition of non-union
Failure of fracture at 2x expected healing time
Classification of non-union
Hypertrophic non-union
=excess mobility and stress
-large callus
-managed by fixation
Atrophic non-union
=poor blood supply
Osteomalacia
Reduced mineralisation of osteoid
Osteoporosis
Low bone mineral density
Low bone mass
Normal mineralisation
Prone to fractures
AO management of fracture principles
Fracture reduction to restore anatomical alignment
Fixation or stabilisation across fracture
Preservation of blood supply and soft tissues, utilisation of gentle reduction techniques
Early and safe mobilisation
Complications of plaster paris
Pressure areas
Venous thromboembolism
Loosening
Indications for internal fixation
Intra-articular fractures
Unstable fractures
Neurovascular damage
Polytrauma
Elderly in which bedrest would result in decline
Long bone fractures
Pathological fractures
Failed conservative stabilisation techniques
Management of factures of shaft of ulna and radius
Mechanism: fall on out-stretched hand
Undisplaced = above elbow cast Displaced = open reduction and compressible plate fixation
Monteggia: proximal
Galeazzia: distal
Fracture dislocations are indication for open reduction and plating
FU x-ray at week 1 and week 2 to ensure reduction
Gartland Classification
Supracondylar fractures
Type I: undsiplaced
Type II: angulated or displaced but posterior cortex intact acting as a hinge
Type III: complete displacement
Type IV: completely displaced and unstable in flexion and extension
Mx: III or IV –> orthopaedic emergency and require K-wire fixation
Management of supracondylar fractures
Gartland classification II-IV are fixed with medial and lateral K-wires
AND above elbow casting
Gartland I: collar and cuff
Complications of supracondylar fractures
Vascular compromise from compression of brachial artery or vascular spasm
If transected - need interposition vein graft
Ischaemic contracture: Volkamn’s
- contraction and fibrosis of forearm
- avoided by early intervention
Neuropraxis
- radial nerve
- anterior interosseous nerve, branch of median nerve
Mal-union
- gun-stock deformity
- recurvatam more common in casting
Epicondyle fracture of humerus
Avulsion-type injuries of apophysis
-high associations with elbow dislocations
Fragment can be trapped in elbow joint
-indication for open fixation
Management: long-arm casting, unless trapped body
Lateral condyle fractures of the humerus
Milcon classification
Type I: # of growth centre capitulum (Salter Harris IV)
Type II: # medial to growth centre and can involve trochlea (Salter Harris II)
Mx: fixation with K-wires or cannulated screws
-if not will be displaced by wrist extensors
Assessment of the hand
Motor innervation
- OK sign = median nerve
- Cross fingers = ulnar nerve
- Extend wrist = radial nerve
Sensory innervation
- Webbing between thumb and index finger on PALMAR surface = median nerve
- Between distal little finger and distal ring finger on palmar/dorsal surface = ulnar nerve
- Webbing between thumb and index finger on DORSAL surface = radial nerve
Testing radial innervation to the hand
Motor = wrist extension
Sensory = Webbing between thumb and index finger on DORSAL surface of the hand
Testing median innervation to the hand
Motor = OK sign
Sensory = Webbing between thumb and index finger on the PALMAR surface of the hand
Testing ulnar innervation to the hand
Motor = cross index and middle finger
Sensory = distal little and ring finger
Complications of supracondylar fractures
Early
- damage to brachial artery
- damage to radial nerve (and median nerve)
- damage to brachial vein
- infection
- haemorrhage
Intermediate
- compartment syndrome
- infection
- secondary haemorrhage
Late
- Volkman ischaemic contracture
- Sudek’s atrophy
- Mal-union –> deformity
- Non-union
Definition of Mal-union
Healing of a fracture in an abnormal position leading to shortening or deformity
Definition of Non-union
Arrest in fracture healing process
Gartland classification of Supracondylar Fractures
Type 1 = undisplayed or minimally displaced
1a: non-displased in two views
1b: minimal displacement, medial cortical buckling
Type 2 = displaced but with INTACT cortex
2a: posterior angulation with intact posterior cortex
2b: rotatory displacement / straight displacement
Type 3 = completely displaced
3a: no cortical contact
3b: soft-tissue interposition
Type 1 Gartland
Type 1 = undisplayed or minimally displaced
1a: non-displased in two views
1b: minimal displacement, medial cortical buckling
Type 2 Gartland
Type 2 = displaced but with INTACT cortex
2a: posterior angulation with intact posterior cortex
2b: rotatory displacement / straight displacement
Type 3 Gartland
Type 3 = completely displaced
3a: no cortical contact
3b: soft-tissue interposition
Holstein-Lewis Fracture
Fracture of the distal third of the humerus resulting in entrapment of the radial nerve.
Management of humeral shaft fractures
Sugar tongue casting for 1-2 weeks
Then functional brace for up to 3 months
Regular clinic follow-up
Presentation of slipper upper femoral epiphysis
Obese children
M: 12 - 15 years
F: 10 - 13 years
Waddling gait
Hip/knee pain
Reduced internal rotation
May be held in external rotation and shorten
20% are bilateral
Investigations for a slipper upper femoral epiphysis
Full joint examination of hip and knee
AP plain radiograph and lateral / frog’s leg pelvis veiws
Management of slipper upper femoral epiphysis
Acute: reduction and cannulated screw fixation
Chronic: no reduction, cannulated screw fixation in-situ
Classification of slipper upper femoral epiphysis
Acute: <3 weeks
Chronic >3 weeks
Stable: able to WB
Unstable: unable to WB
Complications of slipper upper femoral epiphysis
Avascular necrosis
Chondrolysis
Osteoarthritis
Malunion, deformity
Iatrogenic: subtrochanteric fracture if pinned too low
Definition of slipper upper femoral epiphysis
Displacement of epiphysis inferno-posteriorly through the growth plate
Risk factors for slipper upper femoral epiphysis
BMI
Rapid growth
Hypothyroidism
Renal ricketts
Pituitary deficiency
Growth hormone deficiency
Left > right
Male > female
Diagnostic examination finding of SUFE
When hip is flexed –> external rotation
limited ABduction
Shortended, externally rotated
X-ray findings of SUFE
Widening of physics = pre-slip
Klein’s line: line from superior femoral neck should direct head, if it doesn’t = slip
Presentation of hip dislocation
Post hip replacement
Pain
Reduced range of movement
Internally rotated
Hip dislocation post arthroplasty
1-7% of hip replacements
Occurs within 3 months
Recurrence likely
Post arthroplasty films
Check no fracture in native bone, ruling out periprosthetic fracture
Check for changes in angulation that may suggest loosening
Check femoral component is in acetabulum
Management of hip dislocation
Needs relocation
Under sedation or GA
Risk factors for hip dislocation
Patient factors
- female > M 2:1
- weak hip musculature
- age
- obesity
- alcohol
- congenital developmental dysplasia of the hip
Surgical approach
- posterior approach much higher risk
- revision surgery
- capsular excision
Posterior vs lateral approach to hip
Posterior approach
- higher rate of dislocation
- lower sciatic nerve injury
Lateral approach
- less likely to dislocate
- higher risk of sciatic nerve injury
- more likely to bleed
4 compartments of the leg
Anterior compartment
Lateral compartment
Superficial posterior compartment
Deep posterior compartment
Diagnostic criteria for compartment syndrome
= clinical diagnosis
> 30mmHg compartment pressure –> highly suggestive
> 40mmHg compartment pressure or <30mmHg of diastolic BP = diagnostic
Definition of compartment syndrome
Increased pressure in an osteofascial compartment leading to venous and lymphatic occlusion which progressed to limb threatening ischaemia
Management of compartment syndrome
Cast and dressings off
Elevate limb
Analgesia
NBM
IV fluids, reduce rhabdomyolysis
Bloods inc group and save
Reg on-call
CEPOD
Fasciotomy
Differential diagnosis of an acutely painful limb
Acute limb ischaemia
DVT
Compartment syndrome
Missed fracture
